1. Immunisation schedule September 2016
Helen Sisson
@hsisson1

2. After clean water, vaccination is the most effective public health intervention in the world for saving lives and promoting good health (HPA, 2013).
January 2016

3. Focus of session Meningococcal vaccination
Flu vaccination for children and 2016/17 season
Vaccinating during pregnancy
Administration of live vaccines
January 2016

4. 1st Sept 2015
January 2016

5. What is meningococcal disease?
Invasive bacterial infection caused by Neisseria meningitidis,
AKA the meningococcus
Important clinical and public health problem:
rare but serious
disease onset is sudden and often dramatic
The most common clinical presentations are meningitis and
septicaemia: significant morbidity and mortality
Significant case fatality rate ~10% but varies with age,
capsular group, and clinical presentation:
1 in 8 survivors have long term complications
Brain damage, deafness, epilepsy, limb/digit loss, cognitive deficit
January 2016

6.
January 2016

7. Meningococcal Capsular Groups
There are 12 known meningococcal groups, each possessing a distinct outer polysaccharide (sugar) capsule.
The organism is associated with both asymptomatic carriage and invasive disease
>95% of cases are sporadic but occasional outbreaks occur, e.g. in families, schools, universities
January 2016

8. Global distribution of invasive meningococcal disease
Harrison LH, Trotter CL, Ramsay ME. Global Epidemiology of Meningococcal
Disease, in Vaccines against Meningococcus, 2009; 27 Suppl 2:B51-63.
January 2016

9. Laboratory confirmed cases invasive meningococcal disease
England and Wales
January 2016

10. MenB disease by age-group (England & Wales, 2008-13)
January 2016

11. Meningococcal Disease in England
The UK (and ROI) have the highest incidence of IMD in Europe
In England, capsular groups B, W and Y are responsible for nearly all meningococcal infections across all age groups
Routine meningococcal C (MenC) conjugate vaccination introduced in has nearly eliminated invasive MenC disease in England
MenB still accounts for 70% of all laboratory-confirmed meningococcal cases in England and >90% of cases in children and adolescents
January 2016

12. January 2016

13. Who are we vaccinating?
Invasive meningococcal disease by age England & Wales (2006/ /11)

14. The vaccines – Men B
Bexsero® – developed with 4 antigens (OMV + 3 proteins)
Reverse vaccinology
Extensively trialled in infants &
children – no safety concerns
UK is first county to use this vaccine routinely
Aim to provide protection at peak age of 5 months
Protection to last into 2nd year of life
Given at months (with catch-up for those born between 1st May & 30th June)
Men B PHE guidance: vaccination-introduction-from-1-september-2015

15. January 2016

16. Vaccination schedule Sept 2015 (up to 18 years)
Age
Diseases protected against
2 months
Diphtheria, tetanus, whooping cough, polio, Hib, Pneumococcal,
Rotavirus, and Meningococcal group B (Men B)
3 months
Diphtheria, tetanus, whooping cough, polio, Hib, and Rotavirus
4 months
Diphtheria, tetanus, whooping cough, polio, Hib, Pneumococcal
and Men B
12-13 months
Hib/Men C
Pneumococcal, Measles, mumps & rubella (MMR) and Men B
2-6yrs
3yrs 4m
Children’s flu vaccine
Diphtheria, tetanus, whooping cough, polio
MMR (pre-school immunisations)
12-13yrs
HPV (cervical cancer) girls only 2 x doses 6 months apart
13-18yrs
Diphtheria, tetanus, polio (school leavers immunisations)
Men ACWY

17. Administration
Left thigh (ideally on it’s own so that local reactions can be more accurately monitored)
Accurate recording
Bexsero® is associated with higher rates of local and systemic reactions when give with other routine infant vaccinations, but pattern predictable (peak at 6 hours and resolution the following day post vaccination)

18. January 2016

19. January 2016

20. January 2016

21. Laboratory confirmed cases invasive meningococcal disease
England and Wales
January 2016

22. MenW cases by age group England, 2010/11-2014/15*
January 2016

23. Men ACYW - JCVI recommendations: February 2015
In view of rapid increase in cases, known virulence of clonal complex 11 and international experience
JCVI considered situation a public health emergency
Optimal strategy difficult to decide based on wide age distribution
Option to replace MenC doses with quadrivalent conjugate (ACWY) warrant urgent consideration
Toddler dose is given as Hib-MenC – still need the Hib booster
Teenagers are at high risk AND known to have high carriage rates
Vaccination for school years should have rapid impact on carriage and therefore have impact on disease in all age groups
Speed of effect will depend on speed of catch-up campaign
January 2016

24. Men ACWY – The vaccines
Menveo® and Nimenrix ® are the two vaccines recommended for the
routine MenACWY immunisation programme for adolescents
Conjugate vaccines

25. January 2016

26. Administration – the schedule
Catch up to run from Autumn 2015 into 2016
Aimed at adolescents in years 9, 10, 11, 12 & 13 and some university students
Full details regarding the ACYW catch up see:
tachment_data/file/437901/150622_ACWY_bipartite_letter. pdf
January 2016

27. Changes to Men C JCVI advised infants no longer need vaccination
No Men C at 3 months from 1st July
Hib/Men C at 12 months still to be given
From 1st July no longer available as single Men C vaccine
Invasive Men C disease hardly seen
Men ACWY programme = herd immunity
Vaccine update Issue 243,
April 2016

28. Flu vaccination in the UK
Late 1960s: annual flu immunisation recommended to directly protect those in clinical risk groups who are at a higher risk of flu associated morbidity and mortality
2000: flu vaccine policy extended to include all people aged 65 years or over
2010: pregnancy added as a clinical risk category for routine flu immunisation
2013: phased introduction of an annual childhood flu vaccination programme for all children aged 2-16y began with vaccine offered to all children aged 2 and 3 years and seven geographical pilots in primary school aged children
2014: phased introduction of childhood flu vaccination programme continued with vaccine offered to all children aged 2, 3 and 4 years and geographical pilots in primary and secondary school aged children
2015: offer to all 2, 3 & 4 year old children and children of school years 1 & 2
2016: offer to all 2, 3 & 4 year old children and children of school years 1, 2 & 3
January 2016

29. Why vaccinate children against flu?
Extension of the seasonal flu vaccination programme to all children aims to appreciably lower the public health impact of flu by:
Providing direct protection thus preventing a large number of cases of flu in children
Providing indirect protection by lowering flu transmission from children to other children, to adults and to those in the clinical risk groups of any age
Reducing flu transmission in the community will avert many cases of severe flu and flu- related deaths in older adults and people with clinical risk factors
Annual administration of flu vaccine to children is expected to substantially reduce flu- related illness, GP consultations, hospital admissions and deaths
It has been estimated that if just 30% of children had the flu vaccine, there could be fewer deaths and 11 000 fewer hospitalisations due to flu each year
January 2016

30. Which vaccine? Two main types of vaccine available:
Inactivated – by injection
Live - by nasal application
Trivalent vaccines = 2 x A and 1 x B virus types (most inactivated vaccines are trivalent)
Quadrivalent vaccines 2 x A and 2 x B virus types
As quadrivalent vaccines may be better matched and therefore may provide better protection against the circulating B strain(s) than trivalent flu vaccines, the live intranasal vaccine offered to children aged 2yrs and over is a quadrivalent vaccine, as is the inactivated vaccine recommended for children aged 3years and above who cannot received live vaccine
January 2016

31. Fluenz Tetra® More effective than inactivated vaccines
Attenuated whole live virus
Q - So can it cause flu then?
A - No - in addition to being attenuated, (weakened), the live viruses in Fluenz Tetra® have been adapted to cold so that they cannot replicate efficiently at body temperature
Usual contraindications apply
PHE flu in children guidance: programme-qa-for-healthcare-professionals
January 2016

32. National flu immunisation programme 2016/2017 – Key messages
flu immunisation is one of the most effective interventions we can provide to reduce harm from flu and pressures on health and social care services during the winter
it is important to increase flu vaccine uptake in clinical risk groups because of increased risk of death and serious illness if people in these groups catch flu
for a number of years, only around half of patients aged six months to under 65 years in clinical risk groups have been vaccinated
influenza during pregnancy may be associated with perinatal mortality, prematurity, smaller neonatal size, lower birth weight and increased risk of complications for mother
vaccination of health and social care workers protects them and reduces risk of spreading flu to their patients, service users, colleagues and family members
by preventing flu infection through vaccination, secondary bacterial infections such as pneumonia are prevented. This reduces the need for antibiotics and helps prevent antibiotic resistance
January 2016

33. Possible complications…
Common:
bronchitis
otitis media (children), sinusitis
secondary bacterial pneumonia
Less common:
meningitis, encephalitis, meningoencephalitis
primary influenza pneumonia
Risk of most serious illness is higher in children under six months, pregnant women, older people and those with underlying health conditions such as respiratory disease, cardiac disease, long-term neurological conditions or immunosuppression.
Flu during pregnancy may be associated with perinatal mortality, prematurity, smaller neonatal size and lower birth weight
Morbidity and mortality attributed to flu is a key factor in NHS winter pressures and a major cause of harm to individuals especially vulnerable people. The annual flu immunisation programme helps to reduce GP consultations, unplanned hospital admissions and pressure on A&E and is therefore a critical element of the system-wide approach for delivering robust and resilient health and care services during the winter.
The national flu immunisation programme 2016/17

34. Vaccine eligibility: 2016/2017 flu season
all children aged two, three and four years on 31 August 2016
all children of school years 1, 2 and 3 age
all primary school-aged children in former primary school pilot areas
those aged six months to under 65 years in clinical risk groups
all pregnant women (including those who become pregnant during flu season)
those aged 65 years and over (including those becoming 65 years by 31 March 2017
those living in long-stay residential care homes or other long-stay care facilities
carers and household contacts of immunocompromised individuals
Frontline health and social care workers should be provided flu vaccination by their employer. This includes general practice staff.
January 2016

35. Morbidly obese patients
JCVI has advised morbidly obese patients (BMI 40+) could benefit from flu vaccination
those with morbid obesity (BMI>40) found to be at higher risk of hospitalisation and death following pandemic influenza infection
many in this patient group already eligible due to complications of obesity that place them in another risk category
practices need to use clinical judgement to decide whether to vaccinate this group of patients
however, flu vaccinations for morbidly obese patients with no other recognised risk factor will not attract a payment in 2016/17
January 2016

36. Uptake rates 2012/13 – 2015/16
January 2016

37. Vaccines for clinical risk groups
January 2016

38. Which vaccine and how many times?
January 2016

39. 2016/2017 Flu vaccine composition
Trivalent vaccines will contain the following three viruses:
• an A/California/7/2009 (H1N1)pdm09-like virus
• an A/Hong Kong/4801/2014 (H3N2)-like virus
• a B/Brisbane/60/2008-like virus
In addition to the above, the quadrivalent vaccine will also contain:
B/Phuket/3073/2013-like virus
None of the influenza vaccines for the 2016/17 season contain thiomersal as an added preservative.
More detailed information on the characteristics of the available vaccines, including age indications can be found in the Influenza chapter of the Green Book (Immunisation against infectious disease) and the product SPCs.
January 2016

40. Egg allergy Most flu vaccines are prepared from viruses cultured in embryonated hens eggs
Children
Children with egg allergy may be safely vaccinated with the LAIV in any setting
those with both egg allergy and clinical risk factors that contraindicate LAIV (eg immunosuppression) should be offered an inactivated flu vaccine with a very low ovalbumin content (less than 0.12μg/ml)
children with a history of severe anaphylaxis to egg that has previously required intensive care, should be referred to specialists for immunisation in hospital
Adults
Those with egg allergy can receive vaccine with ovalbumin less than 0.12µg/ml
Those with severe anaphylaxis refer for controlled adminstration
There is no ovalbumin free vaccine available in the 2016/2017 flu season

41. Beware of product confusion!

42. Full PHE flu 2016/2017 slideset:

43. Why vaccinate during pregnancy?
Pregnant women may be greater risk if infection is acquired
Passive protection is important for newborns
PHE Flu in pregnancy guidance:
vaccination-in-pregnancy-advice-for-healthcare-professionals
PHE Pertussis in pregnancy guidance:
immunisation-for-pregnant-women-resources-and-training
January 2016

44. What happens in the pregnant immune system?
Innate immunity
Same immediate
response
Non specific
Fast
Adaptive immunity
Highly specific
T & B cells
Antibody production
Takes time
January 2016

45. Administration of antibodies
Passive immunity
Transfer of maternal
antibodies
Administration of antibodies
January 2016

46. Transfer of maternal antibody (passive immunity)
IgG crosses the placenta – most after 32 weeks and reaches maternal levels by 33 weeks
IgG1, IgG2, IgG3, IgG4
Relies heavily on quantity and ability of transfer but can provide newborn with passive protection against many vaccine preventable diseases (VPDs) – tetanus, polio, measles, HBV, mumps, diphtheria….
Predominantly IgA in breast milk
January 2016

47. Flu Flu infection during pregnancy maternal complications
May be associated with preterm birth and SGA babies
Immunisation with inactivated vaccine recommended
Any stage of pregnancy – with each pregnancy
WHO recommendations for uptake are 75%
January 2016

48. January 2016

49. Lab confirmed pertussis cases in England 1998-2014
January 2016

50. Vaccine update: Issue 249, July 2016
January 2016

51. Pertussis vaccination (in pregnancy)
Vaccination containing low dose (d not D) diphtheria
28-32 weeks ideally STOP PRESS
Uptake?
Data from PHE April 2014-March 2015
Prenatal pertussis vaccine coverage in England
January 2016

52. JCVI advised vaccination from 16 weeks
Maternal vaccination in 2nd trimester = neonatal antibodies
Bigger window for vaccination
Advised after 20 week scan
Still okay after 32 weeks although protection for infant not as effective
Vaccine Update Issue 242,
March 2016

53. Interval Spacing of vaccines
Doses of the same inactivated vaccine – 4 weeks apart (or 8w for PCV)
Live vaccines (same or different) – 4 weeks apart
No interval need be observed between:
live and inactivated vaccines
doses of different inactivated vaccines
No evidence exists that inactivated vaccines interfere with the immune response to other inactivated vaccines or to live vaccines
An inactivated vaccine can be administered either simultaneously or at any time before or after a different inactivated vaccine or live vaccine
January 2016

54. April 2015
January 2016

55. Recommendations for giving more than one live attenuated vaccine in current use in the UK
Vaccine combinations
Recommendations
Yellow fever & MMR
4 weeks between
NOT on same day
Varicella (and zoster) & MMR
OR okay to be given on same day
Mantoux testing & MMR
If recent MMR given then wait 4 weeks before Mantoux
If Mantoux initiated then delay MMR until after test read UNLESS measles protection urgently required
All other live vaccines (BCG, rotavirus, LAIV, oral typhoid, yellow fever, varicella, zoster & MMR) and Mantoux testing
Apart from combinations listed above can be given at any time before or after each other.
January 2016

56. Thank you!
With acknowledgement to Public Health England for use/adaptation of slides
January 2016

57. Further reading/resources
Green Book online: against-infectious-disease-the-green-book
Algorithm for uncertain/incomplete vaccination status: of-individuals-with-uncertain-or-incomplete-immunisation- status
January 2016